Immediate fall prevention: the missing key to a comprehensive solution for falling hazard in older adults

The world is witnessing an unprecedented demographic shift due to increased life expectancy and declining birth rates. By 2050, 20% of the global population will be over 60, presenting significant challenges like a shortage of caregivers, maintaining health and independence, and funding extended retirement. The technology that caters to the needs of older adults and their caregivers is the most promising candidate to tackle these issues. Although multiple companies and startups offer various aging solutions, preventive technology, which could prevent trauma, is not a big part of it. Trauma is the leading cause of morbidity, disability, and mortality in older adults, and statistics constitute traumatic fall accidents as its leading cause. Therefore, an immediate preventive technology that anticipates an accident on time and prevents it must be the first response to this hazard category to decrease the gap between life expectancy and the health/wellness expectancy of older adults. The article outlines the challenges of the upcoming aging crisis and introduces falls as one major challenge. After that, falls and their mechanisms are investigated, highlighting the cognitive functions and their relation to falls. Moreover, since understanding predictive cognitive mechanisms is critical to an effective prediction-interception design, they are discussed in more detail, signifying the role of cognitive decline in balance maintenance. Furthermore, the landscape of available solutions for falling and its shortcomings is inspected. Finally, immediate fall prevention, the missing part of a wholesome solution, and its barriers are introduced, and some promising methodologies are proposed.

Old muscle, new tricks: a clinician perspective on sarcopenia and where to next

PURPOSE OF REVIEW

This review offers a contemporary clinical approach to the recognition, prevention and management of sarcopenia, and discusses recent clinically relevant advances in the aetiopathogenesis of muscle ageing that may lead to future therapeutic targets.

RECENT FINDINGS

The key recent directions for sarcopenia are in the diagnosis, understanding molecular mechanisms and management. Regarding the recognition of the condition, it has become increasingly clear that different definitions hamper progress in understanding. Therefore, the Global Leadership in Sarcopenia has been established in 2022 to develop a universally accepted definition. Moreover, substantial work is occurring to understand the various roles and contribution of inflammation, oxidative stress, mitochondrial dysfunction and metabolic dysregulation on skeletal muscle function and ageing. Finally, the role of resistance-based exercise regimes has been continually emphasised. However, the role of protein supplementation and hormone replacement therapy (HRT) are still under debate, and current clinical trials are underway.

SUMMARY

With the global ageing of our population, there is increasing emphasis on maintaining good health. Maintenance of skeletal muscle strength and function are key to preventing frailty, morbidity and death.

Systematic review of candidate prognostic factors for falling in older adults identified from motion analysis of challenging walking tasks

The objective of this systematic review is to identify motion analysis parameters measured during challenging walking tasks which can predict fall risk in the older population. Numerous studies have attempted to predict fall risk from the motion analysis of standing balance or steady walking. However, most falls do not occur during steady gait but occur due to challenging centre of mass displacements or environmental hazards resulting in slipping, tripping or falls on stairs. We conducted a systematic review of motion analysis parameters during stair climbing, perturbed walking and obstacle crossing, predictive of fall risk in healthy older adults. We searched the databases of Pubmed, Scopus and IEEEexplore.A total of 78 articles were included, of which 62 simply compared a group of younger to a group of older adults. Importantly, the differences found between younger and older adults did not match those found between older adults at higher and lower risk of falls. Two prospective and six retrospective fall history studies were included. The other eight studies compared two groups of older adults with higher or lower risk based on mental or physical performance, functional decline, unsteadiness complaints or task performance. A wide range of parameters were reported, including outcomes related to success, timing, foot and step, centre of mass, force plates, dynamic stability, joints and segments. Due to the large variety in parameter assessment methods, a meta-analysis was not possible. Despite the range of parameters assessed, only a few candidate prognostic factors could be identified: older adults with a retrospective fall history demonstrated a significant larger step length variability, larger step time variability, and prolonged anticipatory postural adjustments in obstacle crossing compared to older adults without a fall history. Older adults who fell during a tripping perturbation had a larger angular momentum than those who did not fall. Lastly, in an obstacle course, reduced gait flexibility (i.e., change in stepping pattern relative to unobstructed walking) was a prognostic factor for falling in daily life. We provided recommendations for future fall risk assessment in terms of study design.In conclusion, studies comparing older to younger adults cannot be used to explore relationships between fall risk and motion analysis parameters. Even when comparing two older adult populations, it is necessary to measure fall history to identify fall risk prognostic factors.

Regional differences regarding the occurrence of falls and associated factors in two populations of Brazilian longevous people

Background

Few studies have explored regional asymmetries and their implications for health policies regarding episodes of falls among the population of ≥80 years old in continental and developing countries like Brazil with deep inequalities and sociocultural differences.

Objective

To evaluate the occurrence of falls and their association with functional capacity and nutritional status in the longest oldest-old living in two municipalities in the Northeast and Southeast of Brazil.

Methods

This is a cross-sectional study, with primary data collection in which were included in the research seniors aged 80 years or more, of both sexes, belonging to two Brazilian municipalities of discrepant socioeconomic aspects. The dependent variable was the occurrence of falls in the last year. The independent variables were grouped into demographic aspects, functional capacity and nutritional status. To identify variables that contribute to the occurrence of falls, the multiple logistic regression model, adopts a significance level of 5%.

Results

The sample was composed of 415 oldest-old adults. From the total, 32.3% reported having fallen in the last year, 24.7% in Brejo dos Santos and 37.8% in São Paulo. Among the former population, the mean value of walking speed for those who had falls was 0.27 m/s and for those who had no occurrence of falls was 0.33 m/s; and, among the seniors from São Paulo, the mean values were 0.51 m/s and 0.58 m/s, respectively. Significant correlations between walking speed and falls were verified for both populations, showing that the lower the walking speed, the higher the predisposition to falls. In the final regression model, the occurrence of falls was associated with moderate balance (OR = 5.28; CI: 1.11–25.18) among the longevous people Brejo dos Santos and with very poor functional performance (OR = 16.09; CI:1.46–177.06) among those from São Paulo.

Conclusion

The results pointed out a lower prevalence of falls in longevous people from Brejo dos Santos than in those from São Paulo and differences regarding the associated factors, showing heterogeneity between the two populations; indicating the need for public policies and effective programmes aimed at preventing falls based on the maintenance or increase of functional capacity.

Walking orientation randomness metric (WORM) score: pilot study of a novel gait parameter to assess walking stability and discriminate fallers from non-fallers using wearable sensors

Background

Musculoskeletal disorders can contribute to injurious falls and incur significant societal and healthcare burdens. Identification of fallers from non-fallers through wearable-based gait analysis can facilitate timely intervention to assist mobility and prevent falls whilst improving care and attention for high fall-risk patients. In this study, we use wearable sensor-based gait analysis to introduce a novel variable to assess walking stability in fallers and non-fallers – the Walking Orientation Randomness Metric. The WORM score quantifies the stability, or ‘figure-of-eight’ motion of a subject’s trunk during walking as an indicator of a falls-predictive (pathological) gait.

Methods

WORM is calculated as the ‘figure-of-eight’ oscillation mapped out in the transverse-plane by the upper body’s centre-point during a walking bout. A sample of patients presenting to the Prince of Wales Hospital (Sydney, Australia) with a primary diagnosis of “falls for investigation” and age-matched healthy controls (non-fallers) from the community were recruited. Participants were fitted at the sternal angle with the wearable accelerometer, MetaMotionC (Mbientlab Inc., USA) and walked unobserved (at self-selected pace) for 5-50 m along an obstacle-free, carpeted hospital corridor.

Results

Participants comprised of 16 fallers (mean age: 70 + 17) and 16 non-fallers (mean age: 70 + 9) based on a recent fall(s) history. The (median) WORM score was 17-fold higher (p < 0.001) in fallers (3.64 cm) compared to non-fallers (0.21 cm). ROC curve analyses demonstrate WORM can discriminate fallers from non-fallers (AUC = 0.97). Diagnostic analyses (cut-off > 0.51 cm) show high sensitivity (88%) and specificity (94%).

Conclusion

In this pilot study we have introduced the WORM score, demonstrating its discriminative performance in a preliminary sample size of 16 fallers. WORM is a novel gait metric assessing walking stability as measured by truncal way during ambulation and shows promise for objective and clinical evaluation of fallers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05211-1.

Changes in postural balance associated with a woman's aging process

CONTEXT

Aging causes a progressive worsening in postural balance, affecting functional independence and increasing the risk of falls.

OBJECTIVE

The aim of the study was to evaluate the effect of aging on the static balance in women from 50-years to 89-years of age.

DESIGN

This was a cross-sectional study, with 400 irregularly active women were evaluated and grouped by age: Group 6^th decade (age 50 to 59) ‒ 58 participants; Group 7^th decade (age 60 to 69) ‒ 214 participants; Group 8^th decade (age 70 to 79) ‒ 92 participants; Group 9^th decade (age 80 to 89) ‒ 36 participants. Postural balance was evaluated using a portable force platform in a standard standing position, with Eyes Open (EO) and Eyes Closed (EC).

RESULTS

In the two measurement conditions, the elderly women in Group 9^th decade presented mediolateral displacement and range, and mean velocity greater than the women's values in Groups 6^th and 7^th decade. In the EO e EC situation, the displacement was higher in the elderly Group 9^th decade compared to younger groups. Group 8^th has a mean velocity greater than Group 6^th decade in the EO situation.

CONCLUSIONS

Posturography showed a decline in postural balance with advancing age, suggesting that the 9^th decade of life is a borderline age to this detriment due to an increase in postural instability.

Measures of postural control and mobility during dual-tasking as candidate markers of instability in Huntington's disease

BACKGROUND

Individuals with Huntington's disease (HD) have impairments in performing dual-tasks, however, there is limited information about the effects of changing postural and cognitive demands as well as which measures are best suited as markers of underlying motor-cognitive interference.

METHODS

Forty-three individuals with HD and 15 healthy controls (HC) completed single tasks of walking (Timed Up & Go (TUG), 7 m walk), standing (feet together, feet apart and foam surface) and seated cognitive performance (Stroop, Symbol Digit Modalities Test (SDMT), Delis-Kaplan Executive Function System (DKEFS) Sorting test) and dual cognitive-motor tasks while standing (+ Stroop) and walking (+ DKEFS, TUG cognitive). APDM Opal sensors recorded measures of postural sway and time to complete motor tasks.

RESULTS

Individuals with HD had a greater increase in standing postural sway compared to HC from single to dual-tasks and with changes to support surface. Both groups demonstrated a decrease in gait performance during the TUG cognitive, however, this difference was greater in people with HD compared to HC. While those with HD showed a greater dual-task motor cost compared to HC, both groups behaved similarly as condition complexity increased.

CONCLUSIONS

Standing postural sway is a more sensitive marker of instability than change in standard gait speed, particularly under dual-task conditions. The more complex TUG cognitive is a sensitive measure of walking dual-task performance. The results of this study provide insights about the nature of motor-cognitive impairments in HD and provide support for a distinction between static and dynamic postural control mechanisms during performance of dual-tasks.

[The prevalence of severe falls and associated factors among elderly Brazilians: Results of the 2013 National Health Survey]

The scope of this study was to estimate the prevalence and factors associated with severe falls among elderly Brazilians. It included a transversal study of 10,537 elderly individuals who participated in the National Health Survey (2013). The dependent variable was a report of severe falls in the past year. The independent variables comprised, hierarchically, socio-demographic factors, behavior, health status and functional capacity. Logistic regression was used to obtain the odds ratio (OR) and the confidence interval (95%CI), using the 13.1 Stata program. The prevalence of severe falls was 7.5% (95%CI: 6.7-8.3) and the highest odds were among women (OR: 1.35; 95%CI: 1.03-1.77), 70 to 79 years of age (OR: 1.47; 95%CI: 1.12-1.95) and 80 years and above (OR: 2.00; 95%CI: 1.46-2.74), living without a spouse/partner (OR: 1.37; 95%CI: 1.08-1.74), sedentary in leisure time (OR: 1.55; 95%CI: 1.06-2.26), having multimorbities (OR: 1.54; 95%CI: 1.19-2.00), sleeping difficulties (OR: 2.18; 95%CI: 1.65-2.88), limitations in daily activities (OR: 2.25; 95%CI 1.63 -3.10) and use of a walking aid (OR: 1.89; 95%CI: 1.30-2.73). The prevalence of severe falls was high and multifactorial, enabling the identification of profiles of greater vulnerability, which should be considered in public policies for specific interventions.

Validation of a smartphone embedded inertial measurement unit for measuring postural stability in older adults

BACKGROUND

Identifying older adults with increased fall risk due to poor postural control on a large scale is only possible through omnipresent and low cost measuring devices such as the inertial measurement units (IMU) embedded in smartphones. However, the correlation between smartphone measures of postural stability and state-of-the-art force plate measures has never been assessed in a large sample allowing us to take into account age as a covariate.

RESEARCH QUESTION

How reliably can postural stability be measured with a smartphone embedded IMU in comparison to a force plate?

METHODS

We assessed balance in 97 adults aged 50-90 years in four different conditions (eyes open, eyes closed, semi-tandem and dual-task) in the anterio-posterior and medio-lateral directions. We used six different parameters (root mean square and average absolute value of COP displacement, velocity and acceleration) for the force plate and two different parameters (root mean square and average absolute value of COM acceleration) for the smartphone.

RESULTS

Test-retest reliability was smaller for the smartphone than for the force plate (intra class correlation) but both devices could equally well detect differences between conditions (similar Cohen's d). Parameters from the smartphone and the force plate, with age regressed out, were moderately correlated (robust correlation coefficients of around 0.5).

SIGNIFICANCE

This study comprehensively documents test-retest reliability and effect sizes for stability measures obtained with a force plate and smartphone as well as correlations between force plate and smartphone measures based on a large sample of older adults. Our large sample size allowed us to reliably determine the strength of the correlations between force plate and smartphone measures. The most important practical implication of our results is that more repetitions or longer trials are required when using a smartphone instead of a force plate to assess balance.

Virtual Reality Gait Training to Promote Balance and Gait Among Older People: A Randomized Clinical Trial

Falls are the leading cause of injury and injury-related death in the elderly. This study evaluated the effect of virtual reality gait training (VRGT) with non-motorized treadmill on balance and gait ability of elderly individuals who had experienced a fall. Fifty-six elderly individuals living in local communities participated in this study. Subjects who met the selection criteria were randomly divided into a VRGT group (n = 28) and a control group (n = 28). The VRGT group received VRGT with non-motorized treadmill for 50 min a day for 4 weeks and 5 days a week. The control group received non-motorized treadmill gait training without virtual reality for the same amount of time as the VRGT group. Before and after the training, the one-leg-standing test, Berg Balance Scale, Functional Reach test, and Timed Up and Go test were used to assess balance ability, and the gait analyzer system was used to evaluate the improvement in gait spatiotemporal parameters. In the VRGT group, the balance ability variable showed a significant decrease in the one-leg-standing test and a significant improvement in the Timed Up and Go test. With respect to spatiotemporal gait parameters, velocity and step width decreased significantly in the VRGT group (p < 0.05), and stride length and step length were significantly improved in the VRGT group (p < 0.05). VRGT with non-motorized treadmill has been shown to improve balance and gait ability in the elderly. This study is expected to provide basic data on exercise programs for the elderly to prevent falls.

WITHDRAWN: The epidemiology of emergency presentations for falls across Western Victoria, Australia

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.auec.2019.08.003. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Effect of Senior Dance (DanSE) on Fall Risk Factors in Older Adults: A Randomized Controlled Trial

BACKGROUND

Older people's participation in structured exercise programs to improve balance and mobility is low. Senior Dance is an alternative option, as it may provide a safe and fun way of targeting balance.

OBJECTIVE

The aim was to investigate the effect of Senior Dance on balance, mobility, and cognitive function compared with a control intervention.

DESIGN

The study was a randomized controlled trial.

SETTING/PATIENTS

Eighty-two community-dwelling older people aged 60 years or over and cognitively intact were recruited in Brazil.

INTERVENTION

Participants were randomly allocated to 2 groups: Dance plus education (intervention group) and education alone (control group). The Senior Dance program consisted of 12 weeks of twice-weekly group-based dance classes. Participants in both groups attended a single 1-hour educational session on prevention of falls.

MEASUREMENTS

The primary outcome was single-leg stance with eyes closed. Secondary outcomes were timed sit-to-stand test, standing balance test, timed 4-m walk, and cognitive function tests, for example, Trail Making Test and Montreal Cognitive Assessment.

RESULTS

Of the 82 participants randomized, 71 (87%) completed the 12-week follow-up. Single-leg stance with eyes closed (primary outcome) improved in the Senior Dance group (mean difference [MD] = 2.3 seconds, 95% confidence interval [CI] = 1.1 to 3.6) compared with the control group at follow-up. Senior Dance group performed better in the standing balance tests (MD = 3.7 seconds, 95% CI = 0.6 to 6.8) and were faster in the sit-to-stand test (MD = - 3.1 seconds, 95% CI = -4.8 to -1.4) and 4-m walk test (MD = -0.6 seconds, 95% CI = -1.0 to -0.1). There were no significant between-group differences for cognitive function tests.

LIMITATIONS

Participants and therapists were not blinded.

CONCLUSION

Senior Dance was effective in improving balance and mobility but not cognitive function in community-dwelling older people.

The Relationship between Self-Rated Economic Status and Falls among the Elderly in Shandong Province, China

(1) Background: Older people are more vulnerable and likely to have falls and the consequences of these falls place a heavy burden on individuals, families and society. Many factors directly or indirectly affect the prevalence of falls. The aims of this study were to understand the prevalence and risk factors of falls among the elderly in Shandong, China; the relationship between economic level and falls was also preliminary explored. (2) Methods: Using a multi-stage stratified sampling method, 7070 elderly people aged 60 and over were selected in Shandong Province, China. General characteristics and a self-rated economic status were collected through face to face interviews. Chi-square tests, rank sum tests and two logistic regression models were performed as the main statistical methods. (3) Results: 8.59% of participants reported that they had experienced at least one fall in the past half year. There was a significant difference in experienced falls regarding gender, residence, marital status, educational level, smoking, drinking, hypertension, diabetes, coronary disease, and self-reported hearing. The worse the self-rated economic status, the higher the risk of falling, (poor and worried about livelihood, OR = 3.60, 95%; CI = 1.76–7.35). (4) Conclusions: Women, hypertension, diabetes and self-reported hearing loss were identified as the risk factors of falls in the elderly. The difference of economic level affects the falls of the elderly in rural and urban areas. More fall prevention measures should be provided for the elderly in poverty.

Preliminary Clinical Application of Textile Insole Sensor for Hemiparetic Gait Pattern Analysis

Post-stroke gait dysfunction occurs at a very high prevalence. A practical method to quantitatively analyze the characteristics of hemiparetic gait is needed in both clinical and community settings. This study developed a 10-channeled textile capacitive pressure sensing insole (TCPSI) with a real-time monitoring system and tested its performance through hemiparetic gait pattern analysis. Thirty-five subjects (18 hemiparetic, 17 healthy) walked down a 40-m long corridor at a comfortable speed while wearing TCPSI inside the shoe. For gait analysis, the percentage of the plantar pressure difference (PPD), the step count, the stride time, the coefficient of variation, and the phase coordination index (PCI) were used. The results of the stroke patients showed a threefold higher PPD, a higher step count (41.61 ± 10.7), a longer average stride time on the affected side, a lower mean plantar pressure on the affected side, higher plantar pressure in the toe area and the lateral side of the foot, and a threefold higher PCI (hemi: 19.50 ± 13.86%, healthy: 5.62 ± 5.05%) compared to healthy subjects. This study confirmed that TCPSI is a promising tool for distinguishing hemiparetic gait patterns and thus may be used as a wearable gait function evaluation tool, the external feedback gait training device, and a simple gait pattern analyzer for both hemiparetic patients and healthy individuals.

The epidemiology of emergency presentations for falls across Western Victoria, Australia

BACKGROUND

In order to develop and implement prevention strategies for falls, comprehensive epidemiological data are required. Therefore, this study mapped emergency presentations for falls across the western region of Victoria, Australia, encompassing urban, regional and rural areas.

METHODS

This cross-sectional study utilised electronic data for emergency presentations following a fall from <1m for individuals aged ≥40yr during 2014-2016 inclusive. Age-standardised incidence rates (per 1000 population/year) were calculated for each Local Government Area (LGA).

RESULTS

Age-standardised falls incidence varied across the LGAs, with the lowest occurring in the Rural City of Ararat LGA (4.4; 95%CI:3.5-5.4) and the highest for the City of Warrnambool (25.1; 95%CI:23.7-26.6), Colac-Otway (24.7; 95%CI:23.0-26.4) and Moyne (23.0; 95%CI:21.2-24.8). Patterns were similar for men and women when stratified by sex across these LGAs. For men and women combined, most patients arrived at the hospital using private transportation (55.3%) or road ambulance service (43.1%). Most falls occurred during leisure activities (48.0%) in a home setting (54.8%).

CONCLUSIONS

Higher rates of falls presentations were observed in southern LGAs and most commonly occurred at home, during leisure activity. Future research should identify specific intervention strategies to reduce falls in the region, based on the data reported from this study.

Trunk exercise training improves muscle size, strength, and function in older adults: A randomized controlled trial

The aim of this study was to assess the effectiveness of a multimodal exercise program to increase trunk muscle morphology and strength in older individuals, and their associated changes in functional ability. Using a single-blinded parallel-group randomized controlled trial design, 64 older adults (≥60 years) were randomly allocated to a 12-week exercise program comprising walking and balance exercises with or without trunk strengthening/motor control exercises; followed by a 6-week walking-only program (detraining; 32 per group). Trunk muscle morphology (ultrasound imaging), strength (isokinetic dynamometer), and functional ability and balance (6-Minute Walk Test; 30 second Chair Stand Test; Sitting and Rising Test; Berg Balance Scale, Multi-Directional Reach Test; Timed Up and Go; Four Step Square Test) were the primary outcome measures. Sixty-four older adults (mean [SD]; age: 69.8 [7.5] years; 59.4% female) were randomized into two exercise groups. Trunk training relative to walking-balance training increased (mean difference [95% CI]) the size of the rectus abdominis (2.08 [1.29, 2.89] cm² ), lumbar multifidus (L4/L5:0.39 [0.16, 0.61] cm; L5/S1:0.31 [0.07, 0.55] cm), and the lateral abdominal musculature (0.63 [0.40, 0.85] cm); and increased trunk flexion (29.8 [4.40, 55.31] N), extension (37.71 [15.17, 60.25] N), and lateral flexion (52.30 [36.57, 68.02] N) strength. Trunk training relative to walking-balance training improved 30-second Chair Stand Test (5.90 [3.39, 8.42] repetitions), Sitting and Rising Test (1.23 [0.24, 2.23] points), Forward Reach Test (4.20 [1.89, 6.51] cm), Backward Reach Test (2.42 [0.33, 4.52] cm), and Timed Up and Go Test (-0.76 [-1.40, -0.13] seconds). Detraining led to some declines but all outcomes remained significantly improved when compared to pre-training. These findings support the inclusion of trunk strengthening/motor control exercises as part of a multimodal exercise program for older adults.

Cross-cultural adaptation and measurement properties testing of the Iconographical Falls Efficacy Scale (Icon-FES)

BACKGROUND

The Iconographical Falls Efficacy Scale (Icon-FES) is an innovative tool to assess concern of falling that uses pictures as visual cues to provide more complete environmental contexts. Advantages of Icon-FES over previous scales include the addition of more demanding balance-related activities, ability to assess concern about falling in highly functioning older people, and its normal distribution.

OBJECTIVE

To perform a cross-cultural adaptation and to assess the measurement properties of the 30-item and 10-item Icon-FES in a community-dwelling Brazilian older population.

METHODS

The cross-cultural adaptation followed the recommendations of international guidelines. We evaluated the measurement properties (i.e. internal consistency, test-retest reproducibility, standard error of the measurement, minimal detectable change, construct validity, ceiling/floor effect, data distribution and discriminative validity), in 100 community-dwelling people aged ≥60 years.

RESULTS

The 30-item and 10-item Icon-FES-Brazil showed good internal consistency (alpha and omega >0.70) and excellent intra-rater reproducibility (ICC_2,1=0.96 and 0.93, respectively). According to the standard error of the measurement and minimal detectable change, the magnitude of change needed to exceed the measurement error and variability were 7.2 and 3.4 points for the 30-item and 10-item Icon-FES, respectively. We observed an excellent correlation between both versions of the Icon-FES and Falls Efficacy Scale - International (rho=0.83, p<0.001 [30-item version]; 0.76, p<0.001 [10-item version]). Icon-FES versions showed normal distribution, no floor/ceiling effects and were able to discriminate between groups relating to fall risk factors.

CONCLUSION

Icon-FES-Brazil is a semantically and linguistically appropriate tool with acceptable measurement properties to evaluate concern about falling among the community-dwelling older population.

Disparate effects of training on brain activation in Parkinson disease

OBJECTIVE

To compare the effects of 2 forms of exercise, i.e., a 6-week trial of treadmill training with virtual reality (TT + VR) that targets motor and cognitive aspects of safe ambulation and a 6-week trial of treadmill training alone (TT), on brain activation in patients with Parkinson disease (PD).

METHODS

As part of a randomized controlled trial, patients were randomly assigned to 6 weeks of TT (n = 17, mean age 71.5 ± 1.5 years, disease duration 11.6 ± 1.6 years; 70% men) or TT + VR (n = 17, mean age 71.2 ± 1.7 years, disease duration 7.9 ± 1.4 years; 65% men). A previously validated fMRI imagery paradigm assessed changes in neural activation pretraining and post-training. Participants imagined themselves walking in 2 virtual scenes projected in the fMRI: (1) a clear path and (2) a path with virtual obstacles. Whole brain and region of interest analyses were performed.

RESULTS

Brain activation patterns were similar between training arms before the interventions. After training, participants in the TT + VR arm had lower activation than the TT arm in Brodmann area 10 and the inferior frontal gyrus (cluster level familywise error-corrected [FWEcorr] p < 0.012), while the TT arm had lower activation than TT + VR in the cerebellum and middle temporal gyrus (cluster level FWEcorr p < 0.001). Changes in fall frequency and brain activation were correlated in the TT + VR arm.

CONCLUSIONS

Exercise modifies brain activation patterns in patients with PD in a mode-specific manner. Motor-cognitive training decreased the reliance on frontal regions, which apparently resulted in improved function, perhaps reflecting increased brain efficiency.

Associations between trunk muscle morphology, strength and function in older adults

Skeletal muscle plays an important role in performing activities of daily living. While the importance of limb musculature in performing these tasks is well established, less research has focused on the muscles of the trunk. The purpose of the current study therefore, was to examine the associations between functional ability and trunk musculature in sixty-four community living males and females aged 60 years and older. Univariate and multivariate analyses of the a priori hypotheses were performed and reported with correlation coefficients and unstandardized beta coefficients (β) respectively. The univariate analysis revealed significant correlations between trunk muscle size and functional ability (rectus abdominis: six-minute walk performance, chair stand test, sitting and rising test; lumbar multifidus: timed up and go) as well as trunk muscle strength and functional ability (trunk composite strength: six-minute walk performance, chair stand test, Berg balance performance, sitting and rising test). After controlling for covariates (age and BMI) in the multivariate analysis, higher composite trunk strength (β = 0.34) and rectus abdominis size (β = 0.33) were associated with better performance in the sitting and rising test. The importance of incorporating trunk muscle training into programs aimed at improving balance and mobility in older adults merits further exploration.

Individual housing-based socioeconomic status predicts risk of accidental falls among adults

PURPOSE

Accidental falls are a major public health concern among people of all ages. Little is known about whether an individual-level housing-based socioeconomic status measure is associated with the risk of accidental falls.

METHODS

Among 12,286 Mayo Clinic Biobank participants residing in Olmsted County, Minnesota, subjects who experienced accidental falls between the biobank enrollment and September 2014 were identified using ICD-9 codes evaluated at emergency departments. HOUSES (HOUsing-based Index of SocioEconomic Status), a socioeconomic status measure based on individual housing features, was also calculated. Cox regression models were utilized to assess the association of the HOUSES (in quartiles) with accidental fall risk.

RESULTS

Seven hundred eleven (5.8%) participants had at least one emergency room visit due to an accidental fall during the study period. Subjects with higher HOUSES were less likely to experience falls in a dose-response manner (hazard ratio: 0.58; 95% confidence interval: 0.44-0.76 for comparing the highest to the lowest quartile). In addition, the HOUSES was positively associated with better health behaviors, social support, and functional status.

CONCLUSIONS

The HOUSES is inversely associated with accidental fall risk requiring emergency care in a dose-response manner. The HOUSES may capture falls-related risk factors through housing features and socioeconomic status-related psychosocial factors.

Concurrent validation of an index to estimate fall risk in community dwelling seniors through a wireless sensor insole system: A pilot study

Falls are a major health problem for older adults with immediate effects, such as fractures and head injuries, and longer term effects including fear of falling, loss of independence, and disability. The goals of the WIISEL project were to develop an unobtrusive, self-learning and wearable system aimed at assessing gait impairments and fall risk of older adults in the home setting; assessing activity and mobility in daily living conditions; identifying decline in mobility performance and detecting falls in the home setting. The WIISEL system was based on a pair of electronic insoles, able to transfer data to a commercially available smartphone, which was used to wirelessly collect data in real time from the insoles and transfer it to a backend computer server via mobile internet connection and then onwards to a gait analysis tool. Risk of falls was calculated by the system using a novel Fall Risk Index (FRI) based on multiple gait parameters and gait pattern recognition. The system was tested by twenty-nine older users and data collected by the insoles were compared with standardized functional tests with a concurrent validity approach. The results showed that the FRI captures the risk of falls with accuracy that is similar to that of conventional performance-based tests of fall risk. These preliminary findings support the idea that theWIISEL system can be a useful research tool and may have clinical utility for long-term monitoring of fall risk at home and in the community setting.

Involvement of the end user: exploration of older people's needs and preferences for a wearable fall detection device - a qualitative descriptive study

PURPOSE

To explore the needs and preferences of community-dwelling older people, by involving them in the device design and mock-up development stage of a fall detection device, consisting of a body-worn sensor linked to a smartphone application.

PATIENTS AND METHODS

A total of 22 community-dwelling persons 75 years of age and older were involved in the development of a fall detection device. Three semistructured focus group interviews were conducted. The interview data were analyzed using qualitative descriptive analysis with deductive coding.

RESULTS

The mock-up of a waterproof, body-worn, automatic and manual alerting device, which served both as a day-time wearable sensor and a night-time wearable sensor, was welcomed. Changes should be considered regarding shape, color and size along with alternate ways of integrating the sensor with items already in use in daily life, such as jewelry and personal watches. The reliability of the sensor is key for the participants. Issues important to the alerting process were discussed, for instance, who should be contacted and why. Several participants were concerned with the mandatory use of the smartphone and assumed that it would be difficult to use. They criticized the limited distance between the sensor and the smartphone for reliable fall detection, as it might restrict activity and negatively influence their degree of independence in daily life.

CONCLUSION

This study supports that involving end users in the design and mock-up development stage is welcomed by older people and allows their needs and preferences concerning the fall detection device to be explored. Based on these findings, the development of a "need-driven" prototype is possible. As participants are doubtful regarding smartphone usage, careful training and support of community-dwelling older people during real field testing will be crucial.

Effectiveness of Senior Dance on risk factors for falls in older adults (DanSE): a study protocol for a randomised controlled trial

INTRODUCTION

Strong evidence shows that exercise is effective to improve fall risk factors among older people. However, older people's participation and adherence to exercise programmes is suboptimal. Type of exercise and apathy are reported to be barriers to exercise participation, suggesting that new effective interventions are needed. The primary aim of this randomised controlled trial is to investigate the effect of Senior Dance plus brief education for falls prevention on balance among people aged 60 years or over, compared with a control group receiving only brief education.

METHODS AND ANALYSIS

This single-blind randomised controlled trial will involve 82 community-dwelling older people aged 60 years or over who are cognitively intact. Participants allocated to the intervention group will attend a single educational class on strategies to prevent falls, and will participate in a 12-week, twice-weekly group-based programme of Senior Dance. The Senior Dance consists of different choreographies, which include rhythmic and simple movements with rhythmic folk songs. Participants allocated to the control group will attend the same educational class that intervention group participants will receive, and will be instructed not to take part in any regular exercise programme. The primary outcome will be single-leg stance with eyes closed. Secondary outcomes include: Short Physical Performance Battery, Falls Efficacy Scale, Trail Making Test and the Montreal Cognitive Assessment. Continuous outcomes will be reported using mean (SD) or median (IQR), depending on the distribution of the data. The linear regression approach to analysis of covariance will be used to compare the mean effect between groups. All patients will be included in the analyses following an intention-to-treat approach.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Human Ethics Committee of the São Paulo State University (CAAE 48665215.9.0000.5402). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT02603523, Pre-results.

Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial

BACKGROUND

Age-associated motor and cognitive deficits increase the risk of falls, a major cause of morbidity and mortality. Because of the significant ramifications of falls, many interventions have been proposed, but few have aimed to prevent falls via an integrated approach targeting both motor and cognitive function. We aimed to test the hypothesis that an intervention combining treadmill training with non-immersive virtual reality (VR) to target both cognitive aspects of safe ambulation and mobility would lead to fewer falls than would treadmill training alone.

METHODS

We carried out this randomised controlled trial at five clinical centres across five countries (Belgium, Israel, Italy, the Netherlands, and the UK). Adults aged 60-90 years with a high risk of falls based on a history of two or more falls in the 6 months before the study and with varied motor and cognitive deficits were randomly assigned by use of computer-based allocation to receive 6 weeks of either treadmill training plus VR or treadmill training alone. Randomisation was stratified by subgroups of patients (those with a history of idiopathic falls, those with mild cognitive impairment, and those with Parkinson's disease) and sex, with stratification per clinical site. Group allocation was done by a third party not involved in onsite study procedures. Both groups aimed to train three times per week for 6 weeks, with each session lasting about 45 min and structured training progression individualised to the participant's level of performance. The VR system consisted of a motion-capture camera and a computer-generated simulation projected on to a large screen, which was specifically designed to reduce fall risk in older adults by including real-life challenges such as obstacles, multiple pathways, and distracters that required continual adjustment of steps. The primary outcome was the incident rate of falls during the 6 months after the end of training, which was assessed in a modified intention-to-treat population. Safety was assessed in all patients who were assigned a treatment. This study is registered with ClinicalTrials.gov, NCT01732653.

FINDINGS

Between Jan 6, 2013, and April 3, 2015, 302 adults were randomly assigned to either the treadmill training plus VR group (n=154) or treadmill training alone group (n=148). Data from 282 (93%) participants were included in the prespecified, modified intention-to-treat analysis. Before training, the incident rate of falls was similar in both groups (10·7 [SD 35·6] falls per 6 months for treadmill training alone vs 11·9 [39·5] falls per 6 months for treadmill training plus VR). In the 6 months after training, the incident rate was significantly lower in the treadmill training plus VR group than it had been before training (6·00 [95% CI 4·36-8·25] falls per 6 months; p<0·0001 vs before training), whereas the incident rate did not decrease significantly in the treadmill training alone group (8·27 [5·55-12·31] falls per 6 months; p=0·49). 6 months after the end of training, the incident rate of falls was also significantly lower in the treadmill training plus VR group than in the treadmill training group (incident rate ratio 0·58, 95% CI 0·36-0·96; p=0·033). No serious training-related adverse events occurred.

INTERPRETATION

In a diverse group of older adults at high risk for falls, treadmill training plus VR led to reduced fall rates compared with treadmill training alone.

FUNDING

European Commission.

The Contribution of Hearing and Hearing Loss to Balance Control

This study investigated the hypothesis that a hearing ‘map' of our surroundings is used to maintain balance control. We investigated the effects of sound on postural sway using centre of pressure analysis in 50 subjects with normal hearing, 28 with hearing loss and 19 with vestibular dysfunction. The acoustic environments utilized sound cues that were either present or absent. It was found that auditory cues are utilized by subjects with normal hearing to improve postural sway. The ability to utilize sound for postural control is diminished when there is a hearing loss, but this appears to be overcome by the use of a hearing aid. Patients with additional vestibular deficits exploit auditory cues to a greater degree, suggesting that sensory weighting to enhance the use of auditory cues may be applied when there is diminished sensory redundancy.

Involvement of older people in the development of fall detection systems: a scoping review

BACKGROUND

The involvement of users is recommended in the development of health related technologies, in order to address their needs and preferences and to improve the daily usage of these technologies. The objective of this literature review was to identify the nature and extent of research involving older people in the development of fall detection systems.

METHODS

A scoping review according to the framework of Arksey and O'Malley was carried out. A key term search was employed in eight relevant databases. Included articles were summarized using a predetermined charting form and subsequently thematically analysed.

RESULTS

A total of 53 articles was included. In 49 of the 53 articles, older people were involved in the design and/or testing stages, and in 4 of 53 articles, they were involved in the conceptual or market deployment stages. In 38 of the 53 articles, the main focus of the involvement of older people was technical aspects. In 15 of the 53 articles, the perspectives of the elderly related to the fall detection system under development were determined using focus groups, single interviews or questionnaires.

CONCLUSIONS

Until presently, involvement of older people in the development of fall detection systems has focused mainly on technical aspects. Little attention has been given to the specific needs and views of older people in the context of fall detection system development and usage.

Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes

Background

This programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.

Methods

In the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.

Results

Although 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.

Discussion

The interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.

Trial registration

Current Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.

Fall-related injuries in a low-income setting: Results from a pilot injury surveillance system in Rawalpindi, Pakistan

This study assessed the characteristics and emergency care outcomes of fall-related injuries in Pakistan. This study included all fall-related injury cases presenting to emergency departments (EDs) of the three teaching hospitals in Rawalpindi city from July 2007 to June 2008. Out of 62,530 injury cases, 43.4% (N = 27,109) were due to falls. Children (0–15 years) accounted for about two out of five of all fall-related injuries. Compared with women aged 16–45 years, more men of the same age group presented with fall-related injuries (50% vs. 42%); however, compared with men aged 45 years or more, about twice as many women of the same age group presented with fall-related injuries (16% vs. 9%, P < 0.001). For each reported death due to falls (n = 57), 43 more were admitted (n = 2443, 9%), and another 423 were discharged from the EDs (n = 24,142, 91%). Factors associated with death or inpatient admission were: aged 0–15 years (adjusted odds ratio [aOR] = 1.35), aged 45 years or more (aOR = 1.94), male gender (aOR = 1.15), falls occurring at home (aOR = 3.38), in markets (aOR = 1.43), on work sites (aOR = 4.80), and during playing activities (aOR = 1.68). This ED-based surveillance study indicated that fall prevention interventions in Pakistan should target children, older adult women, homes, and work sites.

Tracking gaze while walking on a treadmill: spatial accuracy and limits of use of a stationary remote eye-tracker

Inaccurate visual sampling and foot placement may lead to unsafe walking. Virtual environments, challenging obstacle negotiation, may be used to investigate the relationship between the point of gaze and stepping accuracy. A measurement of the point of gaze during walking can be obtained using a remote eye-tracker. The assessment of its performance and limits of applicability is essential to define the areas of interest in a virtual environment and to collect information for the analysis of the visual strategy. The current study aims at characterizing a gaze eye-tracker in static and dynamic conditions. Three different conditions were analyzed: a) looking at a single stimulus during selected head movements b) looking at multiple stimuli distributed on the screen from different distances, c) looking at multiple stimuli distributed on the screen while walking. The eye-tracker was able to measure the point of gaze during the head motion along medio-lateral and vertical directions consistently with the device specifications, while the tracking during the head motion along the anterior-posterior direction resulted to be lower than the device specifications. During head rotation around the vertical direction, the error of the point of gaze was lower than 23 mm. The best accuracy (10 mm) was achieved, consistently to the device specifications, in the static condition performed at 650 mm from the eye-tracker, while point of gaze data were lost while getting closer to the eye-tracker. In general, the accuracy and precision of the point of gaze did not show to be related to the stimulus position. During fast walking (1.1 m/s), the eye-tracker did not lose any data, since the head range of motion was always within the ranges of trackability. The values of accuracy and precision during walking were similar to those resulting from static conditions. These values will be considered in the definition of the size and shape of the areas of interest in the virtual environment.

Fall-related emergency department admission: fall environment and settings and related injury patterns in 6357 patients with special emphasis on the elderly

Principals. Throughout the world, falls are a major public health problem and a socioeconomic burden. Nevertheless there is little knowledge about how the injury types may be related to the aetiology and setting of the fall, especially in the elderly. We have therefore analysed all patients presenting with a fall to our Emergency Department (ED) over the past five years. Methods. Our retrospective data analysis comprised adult patients admitted to our Emergency Department between January 1, 2006, and December 31, 2010, in relation to a fall. Results. Of a total of 6357 patients 78% (n = 4957) patients were younger than 75 years. The main setting for falls was patients home (n = 2239, 35.3%). In contrast to the younger patients, the older population was predominantly female (56.3% versus 38.6%; P < 0.0001). Older patients were more likely to fall at home and suffer from medical conditions (all P < 0.0001). Injuries to the head (P < 0.0001) and to the lower extremity (P < 0.019) occurred predominantly in the older population. Age was the sole predictor for recurrent falls (OR 1.2, P < 0.0001). Conclusion. Falls at home are the main class of falls for all age groups, particularly in the elderly. Fall prevention strategies must therefore target activities of daily living. Even though falls related to sports mostly take place in the younger cohort, a significant percentage of elderly patients present with falls related to sporting activity. Falls due to medical conditions were most likely to result in mild traumatic brain injury.

Does the Evaluation of Gait Quality During Daily Life Provide Insight Into Fall Risk? A Novel Approach Using 3-Day Accelerometer Recordings

Background. Many approaches are used to evaluate fall risk. While their properties and performance vary, most reflect performance at a specific moment or are based on subjective self-report. Objective. To quantify fall risk in the home setting using an accelerometer. Methods. Seventy-one community-living older adults were studied. In the laboratory, fall risk was assessed using performance-based tests of mobility (eg, Timed Up and Go) and usual walking abilities were quantified. Subsequently, subjects wore a triaxial accelerometer on their lower back for 3 consecutive days. Acceleration-derived measures were extracted from segments that reflected ambulation. These included total activity duration, number of steps taken, and the amplitude and width at the dominant frequency in the power spectral density, that is, parameters reflecting step-to-step variability. Afterwards, self-report of falls was collected for 6 months to explore the predictive value. Results. Based on a history of 2 or more falls, subjects were classified as fallers or nonfallers. The number of steps during the 3 days was similar ( P = .42) in the fallers (7842.1 ± 6135.6) and nonfallers (9055.3 ± 6444.7). Compared with the nonfallers, step-to-step consistency was lower in the fallers in the vertical axis (amplitude fallers, 0.58 ± 0.22 psd; nonfallers, 0.71 ± 0.18 psd; P = .008); in the mediolateral axis, step-to-step consistency was higher in the fallers ( P = .014). The 3-day measures improved the identification of past and future falls status ( P < .005), compared to performance-based tests. Conclusions. Accelerometer-derived measures based on 3-day recordings are useful for evaluating fall risk as older adults perform daily living activities in their everyday home environment.

Risk factors for falls among older adults: a review of the literature

Falls are one of the major causes of mortality and morbidity in older adults. Every year, an estimated 30-40% of patients over the age of 65 will fall at least once. Falls lead to moderate to severe injuries, fear of falling, loss of independence and death in a third of those patients. The direct costs alone from fall related injuries are a staggering 0.1% of all healthcare expenditures in the United States and up to 1.5% of healthcare costs in European countries. This figure does not include the indirect costs of loss of income both to the patient and caregiver, the intangible losses of mobility, confidence, and functional independence. Numerous studies have attempted to define the risk factors for falls in older adults. The present review provides a brief summary and update of the relevant literature, summarizing demographic and modifiable risk factors. The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors. Recommendations for the clinician to manage falls in older patients are also summarized.

V-TIME: a treadmill training program augmented by virtual reality to decrease fall risk in older adults: study design of a randomized controlled trial

BACKGROUND

Recent work has demonstrated that fall risk can be attributed to cognitive as well as motor deficits. Indeed, everyday walking in complex environments utilizes executive function, dual tasking, planning and scanning, all while walking forward. Pilot studies suggest that a multi-modal intervention that combines treadmill training to target motor function and a virtual reality obstacle course to address the cognitive components of fall risk may be used to successfully address the motor-cognitive interactions that are fundamental for fall risk reduction. The proposed randomized controlled trial will evaluate the effects of treadmill training augmented with virtual reality on fall risk.

METHODS/DESIGN

Three hundred older adults with a history of falls will be recruited to participate in this study. This will include older adults (n=100), patients with mild cognitive impairment (n=100), and patients with Parkinson's disease (n=100). These three sub-groups will be recruited in order to evaluate the effects of the intervention in people with a range of motor and cognitive deficits. Subjects will be randomly assigned to the intervention group (treadmill training with virtual reality) or to the active-control group (treadmill training without virtual reality). Each person will participate in a training program set in an outpatient setting 3 times per week for 6 weeks. Assessments will take place before, after, and 1 month and 6 months after the completion of the training. A falls calendar will be kept by each participant for 6 months after completing the training to assess fall incidence (i.e., the number of falls, multiple falls and falls rate). In addition, we will measure gait under usual and dual task conditions, balance, community mobility, health related quality of life, user satisfaction and cognitive function.

DISCUSSION

This randomized controlled trial will demonstrate the extent to which an intervention that combines treadmill training augmented by virtual reality reduces fall risk, improves mobility and enhances cognitive function in a diverse group of older adults. In addition, the comparison to an active control group that undergoes treadmill training without virtual reality will provide evidence as to the added value of addressing motor cognitive interactions as an integrated unit.

TRIAL REGISTRATION

(NIH)-NCT01732653.

Unintentional injuries: magnitude, prevention, and control

The World Health Organization estimates injuries accounted for more than 5 million deaths in 2004, significantly impacting the global burden of disease. Nearly 3.9 million of these deaths were due to unintentional injury, a cause also responsible for more than 138 million disability-adjusted life years (DALYs) lost in the same year. More than 90% of the DALYs lost occur in low- and middle-income countries (LMICs), highlighting the disproportionate burden that injuries place on developing countries. This article examines the health and social impact of injury, injury data availability, and injury prevention interventions. By proposing initiatives to minimize the magnitude of death and disability due to unintentional injuries, particularly in LMICs, this review serves as a call to action for further investment in injury surveillance, prevention interventions, and health systems strengthening.

The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk?

In this article, we briefly summarize the incidence and significant consequences of falls among older adults, the insufficient effectiveness of commonly used multifactorial interventions and the evidence linking falls and cognitive function. Recent pharmacologic and nonpharmacologic studies that evaluated the effects of cognitive therapy on fall risk are reviewed. The results of this article illustrate the potential utility of multiple, diverse forms of cognitive therapy for reducing fall risk. The article also indicates that large-scale, randomized controlled trials are warranted and that additional research is needed to better understand the pathophysiologic mechanisms underlying the interplay between human mobility, fall risk and cognitive function. Nonetheless, we suggest that multimodality interventions that combine motor and cognitive therapy should, eventually, be incorporated into clinical practice to enable older adults and patients to move safer and with a reduced fall risk.

The global burden of unintentional injuries and an agenda for progress

According to the World Health Organization, unintentional injuries were responsible for over 3.9 million deaths and over 138 million disability-adjusted life-years in 2004, with over 90% of those occurring in low- and middle-income countries (LMIC). This paper utilizes the year 2004 World Health Organization Global Burden of Disease Study estimates to illustrate the global and regional burden of unintentional injuries and injury rates, stratified by cause, region, age, and gender. The worldwide rate of unintentional injuries is 61 per 100,000 population per year. Overall, road traffic injuries make up the largest proportion of unintentional injury deaths (33%). When standardized per 100,000 population, the death rate is nearly double in LMIC versus high-income countries (65 vs. 35 per 100,000), and the rate of disability-adjusted life-years is more than triple in LMIC (2,398 vs. 774 per 100,000). This paper calls for more action around 5 core areas that need research investments and capacity development, particularly in LMIC: 1) improving injury data collection, 2) defining the epidemiology of unintentional injuries, 3) estimating the costs of injuries, 4) understanding public perceptions about injury causation, and 5) engaging with policy makers to improve injury prevention and control.